Non-contrast MRI of Inner Ear Detected Differences of Endolymphatic Drainage System Between Vestibular Migraine and Unilateral Ménière's Disease

Comparison of vestibular aqueduct visualization on computed tomography and magnetic resonance imaging in patients with Ménière's disease

BACKGROUND

The vestibular aqueduct (VA) serves an essential role in homeostasis of the inner ear and pathogenesis of Ménière's disease (MD). The bony VA can be clearly depicted by high-resolution computed tomography (HRCT), whereas the optimal sequences and parameters for magnetic resonance imaging (MRI) are not yet established. We investigated VA characteristics and potential factors influencing MRI-VA visibility in unilateral MD patients.

METHODS

One hundred patients with unilateral MD underwent MRI with three-dimensional sampling perfection with application optimized contrasts using different flip angle evolutions (3D-SPACE) sequence and HRCT evaluation. The imaging variables included MRI-VA and CT-VA visibility, CT-VA morphology and CT-peri-VA pneumatization.

RESULTS

The most frequent type of MRI-VA and CT-VA visualization was invisible VA and continuous VA, respectively. The MRI-VA visibility was significantly lower than CT-VA visibility. MRI-VA visibility had a weak positive correlation with ipsilateral CT-VA visualization. For the affected side, the MRI-VA visualization was negatively correlated with the incidence of obliterated-shaped CT-VA and positively with that of tubular-shaped CT-VA. MRI-VA visualization was not affected by CT-peri-VA pneumatization.

CONCLUSION

In patients with MD, the VA visualization on 3D-SPACE MRI is poorer than that observed on CT and may be affected by its osseous configuration. These findings may provide a basis for further characterization of VA demonstrated by MRI and its clinical significance.

Therapeutic Response of Meniere's Disease Utilizing Sorbus domestica

Introduction Meniere's disease (MD) is a chronic condition characterized by episodic attacks of vertigo, fluctuating hearing loss, and tinnitus. MD can impart a significant socioeconomic impact with associated progressive hearing loss. First-line therapies consist of diuretics and antihistamines, with second-line therapies including intratympanic steroids and pulse therapy. Third-line treatments include endolymphatic sac surgery (ELSS) followed by intratympanic gentamicin injection and/or vestibular neurectomy. The gemmotherapy Sorbus domestica's inherent properties to regulate venous circulation and lymphatic drainage have been utilized in the European literature for the treatment of MD and the patients in this study. Methods Patients presenting for rehabilitation at Pulaski Health and Rehabilitation Facility with a history of vertigo were examined and, through history and specific exam, to define MD. This resulted in six patients whose symptoms and exam were consistent with MD and interfered with their therapeutic progression. These patients were offered and accepted treatment with Sorbus domestica for their MD. Results All patients responded with either resolution or significant improvement in their symptoms and hearing loss. Treatment also resulted in an improved and probably shortened rehabilitative course. All patients had no adverse reactions and were supplied with resources for continual treatment upon discharge. Conclusion Sorbus domestica is a safe and viable treatment option for MD. It has been useful, especially in treatment-resistant diseases, without side effects and can be utilized in initial cases with improvement or resolution of hearing loss.

Meniere's disease is a manifestation of migraine

PURPOSE OF REVIEW

To discuss the theory that Meniere's disease (MD) is a variation of otologic migraine rather than an isolated inner ear condition.

RECENT FINDINGS

In contrast to the approximately 12% of the general population suffering from migraine headaches, 51-60% of patients with MD experience migraine headaches. While pathognomonic for MD, endolymphatic hydrops has also been identified in patients with vestibular migraine. Treatment with the integrative neurosensory rehabilitation approach (diet and lifestyle changes, magnesium and riboflavin supplementation, and when needed, prophylactic medication) to treat the underlying migraine process has been highly effective in patients with MD.

SUMMARY

MD can be understood as a manifestation of migraine such that patients with MD can be effectively treated with migraine therapies.

Visualization and clinical relevance of the endolymphatic duct and sac in Ménière's disease

Background

Ménière's disease (MD) is a chronic inner ear disorder with a multifactorial etiology. Decreased visualization of the endolymphatic duct (ED) and sac (ES) is thought to be associated with MD, although controversy exists about whether this finding is specific to MD. Recent literature has revealed that two distinct ES pathologies, developmental hypoplasia and epithelial degeneration, can be distinguished in MD using the angular trajectory of the vestibular aqueduct (ATVA) or ED-ES system as a radiographic surrogate marker. It has been suggested that these two subtypes are associated with distinct phenotypical features. However, the clinical differences between the ATVA subtypes require further validation.

Research objective

The objective of this study is to investigate whether (1) non-visualization of the ED-ES system is a discriminative radiological feature for MD in a cohort of vertigo-associated pathologies (VAPs) and whether (2) different angular trajectories of the ED-ES system in MD are associated with distinguishable clinical features.

Setting

The study was conducted in the Vertigo Referral Center (Haga Teaching Hospital, The Hague, the Netherlands).

Methods

We retrospectively assessed 301 patients (187 definite MD and 114 other VAPs) that underwent 4h-delayed 3D FLAIR MRI. We evaluated (1) the visibility of the ED-ES system between MD and other VAP patients and (2) measured the angular trajectory of the ED-ES system. MD patients were stratified based on the angular measurements into αexit ≤ 120° (MD-120), αexit 120°-140° (MD-intermediate), or αexit ≥ 140° (MD-140). Correlations between ATVA subgroups and clinical parameters were evaluated.

Results

Non-visualization of the ED-ES system was more common in definite MD patients compared with other VAPs (P < 0.001). Among definite MD patients, the MD-140 subtype demonstrated a longer history of vertigo (P = 0.006), a higher prevalence of bilateral clinical disease (P = 0.005), and a trend toward a male preponderance (p = 0.053). No significant differences were found between ATVA subgroups regarding the presence or severity of auditory symptoms, or the frequency of vertigo attacks.

Conclusion

Non-visualization of the ED-ES system is significantly associated with MD. Among MD patients with a visible ED-ES system, we demonstrated that the MD-140 subtype is associated with a longer disease duration, a higher prevalence of bilateral MD, and a trend toward a male preponderance.

Comparison of radiological abnormalities between the jugular bulb and the vestibular aqueduct in patients with Ménière's disease

Objective

Anatomical variations of the inner ear may contribute to the development of Ménière's disease (MD), which is a complex inner ear disorder histopathologically characterized by idiopathic endolymphatic hydrops (ELH). Abnormalities of the vestibular aqueduct (VA) and the jugular bulb (JB) have been suggested as predisposing factors. Yet, few studies have investigated the correlation between JB abnormalities and VA variations as well as its clinical relevance in these patients. In this retrospective study, we investigated the differences in the incidence of radiological abnormalities of the VA and JB in patients with definite MD.

Methods

Anatomical variations of JB and VA were evaluated based on high-resolution CT (HRCT) in a series of 103 patients with MD (93 unilateral cases and 10 bilateral cases). JB-related indices included JB anteroposterior and mediolateral diameter, JB height, JB type regarding to Manjila classification system, and incidences of JB diverticulum (JBD), JB related inner ear dehiscence (JBID), and inner ear adjacent JB (IAJB). VA-related indices included CT-VA visibility, CT-VA morphology (funnel, tubular, filiform, hollow, and obliterated-shaped type), and peri-VA pneumatization. Radiological indices were compared between MD ears and control ears.

Results

Radiological JB abnormalities were comparable between MD ears and control ears. As for VA-related indices, the CT-VA visibility was lower in MD ears than in control ears (p = 0.004). The distribution of CT-VA morphology was significantly different between MD and control ears (p = 0.013), with a higher proportion of obliterated-shaped type in MD ears (22.1%) than in control ears (6.6%).

Conclusion

Compared with JB abnormalities, the anatomical variations of VA are more likely to be an anatomically predisposing factor for MD.

Functional and Molecular Markers for Hearing Loss and Vertigo Attacks in Meniere's Disease

Meniere's disease (MD) is one of the most complicated diseases in the otologic clinic. The complexity of MD is partially due to the multifactorial etiological mechanisms and the heterogenous symptoms, including episodic vertigo, hearing loss, aural fullness and tinnitus. As a result, the diagnosis of MD and differentiating MD from other diseases with similar symptoms, such as vestibular migraine (VM), is challenging. In addition, it is difficult to predict the progression of hearing loss and the frequency of vertigo attacks. Detailed studies have revealed that functional markers, such as pure tone audiometry (PTA), electrocochleography (ECochG), vestibular evoked myogenic potential (VEMP), caloric test, video head impulse test (vHIT) and magnetic resonance imaging (MRI) could help to evaluate MD with different hearing levels and frequency of vertigo attacks. Investigations of molecular markers such as autoimmunity, inflammation, protein signatures, vasopressin and circadian clock genes in MD are still underway. This review will summarize these functional and molecular markers, address how these markers are associated with hearing loss and vertigo attacks in MD, and analyze the results of the markers between MD and VM.

Pathophysiology and Therapy of Associated Features of Migraine

Migraine is a complex and debilitating disorder that is broadly recognised by its characteristic headache. However, given the wide array of clinical presentations in migraineurs, the headache might not represent the main troublesome symptom and it can even go unnoticed. Understanding migraines exclusively as a pain process is simplistic and certainly hinders management. We describe the mechanisms behind some of the most disabling associated symptoms of migraine, including the relationship between the central and peripheral processes that take part in nausea, osmophobia, phonophobia, vertigo and allodynia. The rationale for the efficacy of the current therapeutic arsenal is also depicted in this article. The associated symptoms to migraine, apart from the painful component, are frequent, under-recognised and can be more deleterious than the headache itself. The clinical anamnesis of a headache patient should enquire about the associated symptoms, and treatment should be considered and individualised. Acknowledging the associated symptoms as a fundamental part of migraine has permitted a deeper and more coherent comprehension of the pathophysiology of migraine.